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INTRODUCTION

The assessment and management of infants who are described, by a parent or other caregiver, as having had a frightening, perhaps life-threatening, event is a challenging problem for clinicians. The fear that the infant may experience additional episodes, perhaps a fatal one, heightens the anxiety level of both families and medical professionals.

DEFINITION

Prior to 1986, parent/caregiver-reported acute events in infants were commonly referred to as an aborted crib death or near-miss sudden infant death syndrome (SIDS). However, in 1986, a National Institutes of Health (NIH) Consensus Development Conference on Infantile Apnea and Home Monitoring recommended use of a newly defined term: apparent life-threatening event (ALTE). The consensus conference defined an ALTE as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging.” In addition, it was recommended that previously used terminology such as aborted crib death or near-miss sudden infant death syndrome be abandoned to avoid implication of a causal association between this type of spell and SIDS.

Apparent life-threatening events were described in the Consensus Development Conference statement as a “chief complaint that describes a general clinical syndrome.” Although the definition of an apparent life-threatening event appeared straightforward, in practice, determining whether or not an infant experienced an ALTE has been extraordinarily difficult for clinicians, and it has frequently led to hospital admissions and testing of questionable value. In response to this dilemma, in 2016, a clinical practice guideline was published by the American Academy of Pediatrics (AAP), which suggested using event characteristics, rather than the term ALTE, to describe events and suggested new terminology, brief resolved unexplained events (BRUE), be used for events that met specific characteristics. The definition of a BRUE is a sudden, brief (ie, < 1minute), and now resolved episode with at least 1 of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone (hyper- or hypotonia); and altered responsiveness. In addition, criteria were provided to risk stratify infants having events that met the BRUE criteria, and management guidelines were provided for infants who met criteria to be considered low risk.

INCIDENCE

Since the terminology is newly developed, there are no data on the incidence of BRUE. Data regarding the incidence of ALTEs are also limited, due to the imprecise manner in which this terminology has been applied. However, the incidence of ALTE was estimated to be 0.05% to 1% in population-based studies. Some perspective on the occurrence of idiopathic ALTE can be obtained from the Collaborative Home Infant Monitoring Evaluation (CHIME study), which was conducted at 5 medical centers (located in Cleveland, Toledo, Chicago, Los Angeles, and Honolulu) during the mid-1990s. This study included a systematic review of infants who presented with diagnoses consistent with ALTE and found that a typical urban medical center hospital provides care for about 1 case of possible ALTE each week and that approximately 20% of such cases will be considered an idiopathic ALTE.